Is an interlaminar epidural injection (code 62321) medically necessary for a patient with cervical radiculopathy, taking Meloxicam (generic name: Meloxicam), and having a history of cancer, who has failed to improve with conservative treatments?

Medical Necessity Assessment for Cervical Interlaminar Epidural Steroid Injection (Code 62321)

This cervical interlaminar epidural steroid injection is NOT medically necessary based on the most recent high-quality evidence, which shows moderate certainty that epidural injections (with or without steroids) provide little to no pain relief for chronic radicular spine pain compared to sham procedures, and the patient lacks documentation of a comprehensive pain management program. 1

Critical Evidence Against Medical Necessity

The 2025 BMJ clinical practice guideline—the highest quality and most recent evidence available—fundamentally changes the landscape for epidural steroid injections:

• Moderate certainty evidence demonstrates that epidural injection of local anesthetic with steroids for chronic radicular spine pain probably has little to no effect on pain relief compared to sham procedures. 1
• The guideline panel reviewed all available evidence and found no high certainty evidence of important pain relief for any interventional procedure for chronic radicular spine pain. 1
• Between 1997 and 2014, the FDA Adverse Event Reporting System captured 90 serious adverse events within minutes to 48 hours after epidural corticosteroid injections, including death, spinal cord infarction, paraplegia, quadriplegia, cortical blindness, stroke, seizures, and brain edema. 1

Specific Deficiencies in This Case

Missing Comprehensive Pain Management Program

• The case explicitly states inability to determine if the injection is part of a comprehensive pain management program—this is a mandatory criterion. 2
• Epidural injections must be provided as part of a comprehensive pain management program that includes physical therapy, patient education, psychosocial support, and oral medications. 2
• The documentation shows only a 1-week trial of Meloxicam 15mg daily, which is grossly inadequate. 2

Insufficient Conservative Treatment Duration

• The patient requires failure of at least 4-6 weeks of conservative treatments including physical therapy, NSAIDs, and activity modification before epidural injection consideration. 2
• This patient's documentation shows only 1 week of Meloxicam trial—not the required 4+ weeks of comprehensive conservative management. 2
• No documentation of physical therapy trial is present in the submitted records. 2

Inadequate Imaging Timeline

• Advanced diagnostic imaging must be performed within 24 months prior to initiating epidural injections. 2
• The MRI from the specified date meets this criterion, showing C6-7 degenerative changes with moderate spinal canal and moderate-to-severe neural foraminal stenosis. 2

Clinical Presentation Analysis

Radiculopathy Criteria Assessment

The patient does meet radiculopathy criteria for cervical spine:

• Pain, numbness, and weakness radiating to the right shoulder, posterolateral arm, elbow, distal anterior forearm, palm, and fingers 1-3 constitutes true radicular pain in cervical distribution. 2
• Radiculopathy in neck pain is defined as pain, numbness, or weakness in the shoulder, arm, wrist, or hand. 2
• MRI demonstrates anatomic correlation with C6-7 moderate-to-severe bilateral neural foraminal stenosis. 2

Concerning Complicating Factors

• History of head/neck cancer with radiation therapy (tonsil cancer, date specified) creates significant risk for catastrophic complications from cervical epidural injection. 1
• Post-radiation tissue changes increase risk of dural puncture, vascular injury, and infection. 1
• The patient reports unexpected rib fractures suggesting possible osteoporosis—unchecked and potentially increasing procedural risks. 2

Guideline Conflicts and Resolution

Conflicting Recommendations

There is stark disagreement between guidelines:

• The 2025 BMJ guideline (highest quality, most recent) provides strong recommendation AGAINST epidural injections for chronic radicular spine pain based on moderate certainty evidence of no benefit. 1
• Older guidelines from interventional pain societies recommend FOR epidural injections, but these are characterized as consensus-based rather than evidence-based. 1
• A 2023 synthesis of 21 clinical practice guidelines found no consistency in recommendations for or against any interventional procedure, even after accounting for guideline quality. 1

Evidence Quality Hierarchy

• Positive results for epidural injections were three times more likely when reviews were authored by interventionalists versus non-interventionalists, suggesting significant bias in the literature. 1
• The 2025 BMJ guideline used rigorous network meta-analysis methodology and explicitly prioritized patient-important outcomes (morbidity, mortality, quality of life). 1

Required Actions Before Approval

If this case were to be reconsidered in the future, the following would be mandatory:

1. Complete minimum 4-6 weeks of documented physical therapy with objective functional assessments. 2
2. Trial of adequate conservative pharmacologic management beyond 1 week of Meloxicam. 2
3. Documentation of comprehensive pain management program including patient education and psychosocial support. 2
4. Evaluation and treatment of suspected osteoporosis given history of pathologic rib fractures. 2
5. Detailed shared decision-making discussion documenting patient understanding that moderate certainty evidence shows no benefit over sham procedure, with risks including paralysis and death. 1
6. Oncology clearance given history of head/neck radiation and altered tissue planes. 1

Alternative Treatment Considerations

• Optimize conservative management first: structured physical therapy program, multimodal analgesia, neuropathic pain medications (gabapentinoids, SNRIs), and activity modification. 3, 4
• Consider surgical evaluation if progressive neurologic deficits develop, as the natural history of cervical radiculopathy is generally favorable with conservative management. 5, 4
• The long-term prognosis of cervical radiculopathy is favorable with conservative treatment in most cases. 4

Common Pitfalls to Avoid

• Do not approve interventional procedures based solely on patient request or provider preference when high-quality evidence shows no benefit. 1
• Do not substitute a brief medication trial for comprehensive conservative management including physical therapy. 2
• Do not ignore the requirement for documented comprehensive pain management program—this is not optional. 2
• Do not overlook radiation therapy history when assessing procedural risks in cervical spine. 1